Healthcare Provider Details

I. General information

NPI: 1891182416
Provider Name (Legal Business Name): STACY LYNNE SIMON DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6504 CLEMSON ST
BRADENTON FL
34207-5622
US

IV. Provider business mailing address

6504 CLEMSON ST
BRADENTON FL
34207-5622
US

V. Phone/Fax

Practice location:
  • Phone: 941-526-5383
  • Fax:
Mailing address:
  • Phone: 941-526-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH13645
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: